Current And Emerging Techniques For Hallux Rigidus

Brent D. Haverstock, DPM, FACFAS

   In a study of this technique, Goucher and Coughlin examined the use of dome-shaped reamers to prepare the joint surfaces and a low-profile dorsal titanium plate for internal fixation.42 The study involved 50 patients (54 feet) who had first MPJ arthrodesis. The study authors employed dome-shaped power reamers to facilitate congruous, cancellous bone surfaces and used a dorsal titanium plate with preset valgus and dorsiflexion. Researchers assessed the patients at an average follow-up of 16 months and a minimum of one year.

   In terms of results, Goucher and Coughlin reported a 31 point increase in the AOFAS score from an average 51 points preoperatively to 82 points postoperatively, and a significant reduction of pain from a preoperative mean of 6.3 on the VAS to a mean of less than one point postoperatively.42 Thirty-two patients (35 feet) rated their outcome as “excellent” while 16 patients (16 feet) had “good” results. The researchers also reported a 92 percent union rate and a 4 percent revision rate.

   Hyer and colleagues demonstrated similar findings in a retrospective review of 45 patients who had a locking plate with a compression screw for fixation of hallux rigidus correction.43 They reported a mean time to union of 51.1 days and a 93 percent fusion rate (42 out of 45 feet) with three nonunions. Researchers have also demonstrated that this technique allows for immediate postoperative ambulation.44

   Metallic resurfacing of the metatarsal side of the metatarsophalangeal joint has shown promising results as an alternative to arthrodesis. Arthrodesis can result in difficulty squatting or kneeling, running and wearing shoes with a high heel. The patient population developing hallux rigidus appears to be younger than previously reported. This is likely due to increased activity and the type of sports that they are playing. These patients are often resistant to the idea of an arthrodesis and are looking for alternatives to maintain joint motion.

   Kline and Hasselman reviewed 26 patients (30 implants) with stage II or III hallux rigidus who had metatarsal head resurfacing with the HemiCAP® implant.45 At 27 months post-op, the researchers noted improvements in mean active range of motion (from 10.7 to 47.9 degrees), mean passive range of motion (from 28 to 66.3 degrees) and mean AOFAS scores (from 51.5 to 94.1). The average time for returning to work was seven days, according to the study. All patients reported excellent satisfaction at 60 months and the study authors also noted an 87 percent implant survivorship at this time.

   Another promising technique in preservation of the first MPJ is the use of a human acellular dermal regenerative matrix as an interpositional arthroplasty graft. Berlet, Hyer and colleagues evaluated this procedure in which they placed the graft in the joint via a parachute technique covering the head of the first metatarsal head and the sesamoid complex.46 Of the first nine consecutive patients in the original study cohort, six patients were available for follow-up. There were no reported complications at the mean follow-up of 12.7 months and the authors noted an increased mean AOFAS score from 63.9 to 87.9. In a subsequent study of these patients with an average follow-up of 5.43 years, the authors found that all patients were satisfied with their results and no patient had a subsequent fusion or additional procedure on the first MPJ.47 The study authors recommend this technique for the treatment of active patients with advanced hallux rigidus who want to delay a fusion of their first MPJ.

Final Notes

Hallux rigidus remains a complex problem that affects a seemingly larger segment of the population. The desire to maintain joint range of motion is common among individuals facing surgical intervention. Studies continue to support the role of arthrodesis with its predictable outcome but advances in procedures aimed at preserving range of motion appear to be promising.

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